Hyperosmolar hyperglycemic state: Difference between revisions
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==Background== | ==Background== | ||
*Prototypical patient is elderly with uncontrolled type II [[DM]] without adequate access to H2O | |||
*Occurs due to 3 factors: | |||
**Insulin resistance or deficiency | |||
**Increased hepatic gluconeogenesis and glycogenolysis | |||
**Osmotic diuresis and dehydration followed by impaired renal excretion of glucose | |||
***May result in TBW losses of 8-12L | |||
*Ketosis usually absent (may be mild) | |||
*Cerebral edema is uncommon complication (case reports) | |||
*Estimated mortality 10-20%, usually due to underlying precipitant<ref>Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care. 2014; 37(11):3124-31.</ref> | |||
**In contrast to [[DKA]], in which mortality is 1-5% | |||
**Incidence of HHS < 1% of hospital admissions of patients with diabetes | |||
===Precipitants=== | ===Precipitants=== | ||
*[[Pneumonia (Main)]] | |||
*[[Urinary tract infection]] | |||
*Medication non-adherence | |||
*[[Cocaine intoxication]] | |||
*Meds: [[Beta-blockers]], diuretics | |||
*[[GI bleed]] | |||
*[[Pancreatitis]] | |||
*[[Heat Emergencies|Heat related emergencies]] | |||
*[[Acute coronary syndrome]] | |||
*[[Stroke]] | |||
==Clinical Features== | ==Clinical Features== | ||
*Dehydration | *[[Dehydration]] | ||
**Hypotension | **[[Hypotension]] | ||
*Seizure (15% of | *[[Seizure]] (15% of patients) | ||
*Altered mental status | *[[Altered mental status]] | ||
*Lethargy/coma | *Lethargy/[[coma]] | ||
==Diagnosis== | ==Differential Diagnosis== | ||
{{Hyperglycemia DDX}} | |||
==Evaluation== | |||
===Work Up=== | |||
*Chemistry | |||
*Serum osm | |||
*[[Lactate]] | |||
*Serum ketones | |||
*CBC | |||
*Also consider: | |||
**Blood cultures | |||
**[[Urinalysis]]/Urine culture | |||
**[[LFTs]] | |||
**Lipase | |||
**[[Troponin]] | |||
**[[CXR]] | |||
**[[ECG]] | |||
**[[Head CT]] | |||
===Diagnosis=== | |||
*Glucose >600 | *Glucose >600 | ||
*Osm > | *Osm >320 | ||
*Bicarb >15 | *Bicarb >15 | ||
*pH >7.3 | *pH >7.3 | ||
*Serum ketones negative or mildly positive | *Serum ketones negative or mildly positive | ||
*Neurologic abnormalities frequently present (coma in 25-50% of cases) | |||
== | ==Management== | ||
#[[Fluid replacement]] | |||
#*Average fluid deficit is 8-12L | |||
#**50% should be replaced over the initial 12hr | |||
#**May have to replace slower if patient has cardiac/renal impairment | |||
#**Aggressiveness of fluid replacement must be weighed against the risk of cerebral edema, which increases with younger age<ref>Stoner GD. Hyperosmolar Hyperglycemic State. Am Fam Physician. 2005 May 1;71(9):1723-1730. http://www.aafp.org/afp/2005/0501/p1723.html</ref> | |||
#[[Hypokalemia]] | |||
#*Must treat aggressively | |||
#*Once adequate urinary output has been established K+ replacement should begin | |||
#[[Hyperglycemia]] | |||
#*Do not start insulin until K > 3.3 and adequate urinary output has been established | |||
#[[Hypomagnesemia]] | |||
#*Repletion will help correct [[hypokalemia]] | |||
#[[Hypophosphatemia]] | |||
#*Routine correction unnecessary unless phos <1.0 | |||
#Fluid replacement | |||
# | |||
# | |||
# | |||
#Hypokalemia | |||
# | |||
# | |||
#Hyperglycemia | |||
# | |||
#Hypomagnesemia | |||
# | |||
#Hypophosphatemia | |||
# | |||
[[File:HHS.jpg]] | [[File:HHS.jpg]] | ||
==Disposition== | ==Disposition== | ||
*Most | *Most patients require ICU admission | ||
==See Also== | ==See Also== | ||
*[[ | *[[Diabetes mellitus (main)]] | ||
*[[ | *[[Diabetic ketoacidosis]] | ||
*[[Hypoglycemia]] | *[[Hypoglycemia]] | ||
== | ==References== | ||
<references/> | |||
[[Category:Endocrinology]] | |||
[[Category: |
Latest revision as of 16:06, 28 September 2019
Background
- Prototypical patient is elderly with uncontrolled type II DM without adequate access to H2O
- Occurs due to 3 factors:
- Insulin resistance or deficiency
- Increased hepatic gluconeogenesis and glycogenolysis
- Osmotic diuresis and dehydration followed by impaired renal excretion of glucose
- May result in TBW losses of 8-12L
- Ketosis usually absent (may be mild)
- Cerebral edema is uncommon complication (case reports)
- Estimated mortality 10-20%, usually due to underlying precipitant[1]
- In contrast to DKA, in which mortality is 1-5%
- Incidence of HHS < 1% of hospital admissions of patients with diabetes
Precipitants
- Pneumonia (Main)
- Urinary tract infection
- Medication non-adherence
- Cocaine intoxication
- Meds: Beta-blockers, diuretics
- GI bleed
- Pancreatitis
- Heat related emergencies
- Acute coronary syndrome
- Stroke
Clinical Features
- Dehydration
- Seizure (15% of patients)
- Altered mental status
- Lethargy/coma
Differential Diagnosis
Hyperglycemia
- Physiologic stress response (rarely causes glucose >200 mg/dL)
- Diabetes mellitus (main)
- Hemochromatosis
- Iron toxicity
- Sepsis
Evaluation
Work Up
- Chemistry
- Serum osm
- Lactate
- Serum ketones
- CBC
- Also consider:
Diagnosis
- Glucose >600
- Osm >320
- Bicarb >15
- pH >7.3
- Serum ketones negative or mildly positive
- Neurologic abnormalities frequently present (coma in 25-50% of cases)
Management
- Fluid replacement
- Average fluid deficit is 8-12L
- 50% should be replaced over the initial 12hr
- May have to replace slower if patient has cardiac/renal impairment
- Aggressiveness of fluid replacement must be weighed against the risk of cerebral edema, which increases with younger age[2]
- Average fluid deficit is 8-12L
- Hypokalemia
- Must treat aggressively
- Once adequate urinary output has been established K+ replacement should begin
- Hyperglycemia
- Do not start insulin until K > 3.3 and adequate urinary output has been established
- Hypomagnesemia
- Repletion will help correct hypokalemia
- Hypophosphatemia
- Routine correction unnecessary unless phos <1.0
Disposition
- Most patients require ICU admission
See Also
References
- ↑ Pasquel FJ, Umpierrez GE. Hyperosmolar hyperglycemic state: a historic review of the clinical presentation, diagnosis, and treatment. Diabetes Care. 2014; 37(11):3124-31.
- ↑ Stoner GD. Hyperosmolar Hyperglycemic State. Am Fam Physician. 2005 May 1;71(9):1723-1730. http://www.aafp.org/afp/2005/0501/p1723.html